GOLD Strategy Update 2023: Rationale and Clinical Implications in Indian Perspective

Chronic obstructive lung disease (COPD) is a major contributor to global disease burden with a huge socioeconomic impact. Global initiative for chronic obstructive lung disease (GOLD) strategy update 2023 is a step forward in the direction of evidence-based practice. Key topics like taxonomic classification, ABE grouping, single inhaler triple therapy, correct use of inhalers, etc. would have a positive impact on documentation and prescription practices in COPD management. The tobacco consumption habits are peculiar in India. There is a variation in prevalence estimates across diverse cultures. Non-smoking risk factors are important in Indian subcontinent especially in female and younger populations. We discuss the rationale of latest GOLD strategy update, its implications, and challenges in the management of COPD in Indian context.

Risk factors for cardiovascular disease among adults in rural Lucknow: A community-based study

Background: Cardiovascular disease is the leading cause of death in the world, and in addition to the complexity of CVD management, there are well-documented risk factors whose different effects dictate the need for region-specific research. Aim and Objectives: This study aimed at investigating the risk factors of CVD among adults in rural Lucknow. Materials and Methods: This cross-sectional survey was conducted from April 1 to December 31, 2018. Sociodemographic data, anthropometric data, and blood pressure were recorded. Individuals who were at least 18 years of age residing in the study area minimum 2 years and on condition that participants gave their written consent for enrollment in the survey. Data analyses were done using Microsoft Excel. Results: The study participants comprised of 364 adults, with average age of 35 ± 16 years, 200 (54.9%) were males and 164 (45.1%) were females. The mean values of hip circumference, waist circumference, waist and hip ratio, and diastolic blood pressure were higher among females than males. Waist and hip circumference in male participants whereas in female participant’s body mass index with systolic blood pressure and diastolic blood pressure were significantly correlated. Conclusion: Rural females were at more risk of higher than-normal blood pressure, compare to males. The significant incidence of CVD risk factors in rural areas, particularly among those who are overweight or obese, necessitates early clinical identification. CVD screening, prevention, and control must be prioritized in health initiatives.

Approach to Optimal Oxygen Therapy in the Management of COVID-19 Patients during Pandemic: An Indian Perspective

Background: A sudden spike in positive cases in the second wave of COVID-19 pandemic took Government, Public, and Healthcare system by surprise in India. It was bigger and deadlier than the first wave. Unsupervised oxygen delivery practiced in oxygen buses and pandals by untrained individuals was a matter of concern and should have been discouraged. This resulted in wastage of oxygen which could have led to catastrophic consequences. Awareness about the optimal use of oxygen by identifying errors in prescribing/practicing oxygen therapy will go a long way in saving lives. This article provides a quick review of oxygen therapy with a focus on the rationale use of oxygen and plausible solutions to mitigate wastage in a resource-constrained scenario, such as the COVID-19 pandemic.

Novel technique of sutureless glueless scleral fixated intraocular lens (SFIOL)

Purpose: To report results of a novel technique for sutureless, glueless intrascleral fixation of three-piece posterior chamber intraocular lens (IOL) using 26-G needle for management of aphakia. Methods: In this prospective series, 30 eyes of 20 patients with aphakia, subluxated IOL, or crystalline lens were included. 26-G-needle-guided intrascleral fixation of three-piece posterior chamber IOL was performed according to the described technique. The patients were evaluated on day 2, 1 week, 6 weeks, and 3 months postoperatively for change in best-corrected visual acuity (BCVA), intraocular pressure (IOP), IOL centration, and any other complications. The postoperative tilt of the IOL was indirectly measured by determining the lenticular astigmatism which in turn was calculated by the difference between net corneal astigmatism and refractive astigmatism. Paired t-test was used to determine the significance of any association between the preoperative and postoperative BCVA and IOP. P < 0.05 was considered significant. Results: Of 30 eyes (n = 30 patients), 18 were surgical aphakia, 6 traumatic aphakia, 5 subluxated IOL, and 1 ectopia lentis (Marfan syndrome). The mean preoperative BCVA was 1.37 ± 0.37 (logMAR) and postoperative BCVA at 3 months was 0.37 ± 0.29 (logMAR). A significant improvement in the mean BCVA (P < 0.05) was observed after the procedure. The mean IOP preoperatively was 13.33 ± 4.18 and postoperatively at 3 months was 12.82 ± 3.97 (P > 0.05), which was not significant. None of the eyes developed any intraoperative and postoperative complications. The IOLs had appropriate centration and stability. Conclusion: We have developed this new technique for intrascleral IOL fixation which is quite simple, cost-effective, minimally invasive, neither requires glue nor suture and gives consistent outcome.

Endoillumination (chandelier) and wide-angle viewing-assisted fine-needle aspiration biopsy of intraocular mass lesions

Fine-needle aspiration biopsy (FNAB) of intraocular mass lesions is an important intervention in the presence of diagnostic difficulty. FNAB of intraocular mass lesions is also likely to become more commonly recommended for prognostication of tumors such as choroidal melanoma. The most commonly described approach for tumor localization and visualization during FNAB is transillumination and indirect ophthalmoscopic viewing. Herein, we report endoillumination (chandelier) and wide-angle viewing assisted, microscope-based approach for FNAB in two patients using two port minimally invasive vitreoretinal surgical approach. The submission is supported by a video demonstration. The entire procedure was completed under the microscope. Adequate sample was obtained. In the first patient, the inflammatory nature of the lesion was confirmed though magnetic resonance imaging had been reported as melanoma. In the second patient, a clinical diagnosis of amelanotic melanoma was confirmed. Endoillumination-assisted FNAB of intraocular mass lesions is easier to learn and more precise and hence carries lesser risks.

Electronic Cigarettes: Facts and Myths.

E-cigarettes are devices designed to deliver nicotine to users without burning tobacco. These are being marketed globally as a healthier substitute to the conventional cigarettes and as smoking quitting aids. The use of these devices has increased recently in developed countries with approximately 1.3 million users reported in the United Kingdom in 2013. Perception of these products as a safe alternative, appealing advertisements, and lax regulatory policies have helped gain popularity among the public. Despite all these claims, a debate is on-going because of insufficient scientific data regarding safety and efficacy of e-cigarettes as well as awareness of the potential health hazards. To solve the dilemma, more scientific studies in this field are required. Prompt regulatory response with strict vigilance on marketing and advertising may be desirable in the interest of users and public at large.

Evaluating most probable number method to count and isolate viable methylotrophs

Nine different receptacles were tested with the MPN method to determine which receptacle was most reliable and economical for MPN counts. Results showed that 96 well PCR plate were the best vessels for this type of analysis and facilitated the isolation of viable Methylotrophs.

Prevalence of bronchial asthma in school children of 6-13 years of age in Shimla City.

Background. Asthma is a major public health problem worldwide. However, there is limited data on asthma prevalence among school children in Shimla. The present study was undertaken to determine the prevalence of asthma in Shimla city and also to examine the different factors influencing its occurrence. Methods. This was a questionnaire-based study (International Study of Asthma and Allergies in Childhood [ISAAC] protocol) carried out in four randomly selected schools in the city of Shimla. The questionnaire was pre-tested in 50 school children. The age group included in the study was 6-13 years. The questionnaire was distributed to all the children (n=1136). A response rate of 89.5% was achieved. The socio-economic status was determined on the basis of monthly income (cumulative square root value method). The ISAAC questionnaire was given standard scores. Various factors influencing the prevalence of asthma, such as socio-economic status, history of asthma and other allergic disorders in the family, type of cooking fuel used, history of active and passive smoking were elucidated from the history. Results. Overall prevalence of asthma in our study was found to be 2.3 percent. Boys had a higher prevalence (3.1%) than girls (1.4%). We found a significant association between asthma prevalence and family history of asthma and other atopic manifestations. There was no significant association of socio-economic factors and exposure to smoking with prevalence of asthma. Conclusion. In the present study, the prevalence of bronchial asthma in school children in the age group of 6-13 years is 2.3 percent.

Hydatid disease of the lung mimicking a pericardial cyst.

We report a young girl who presented to us with chest discomfort and had a paracardiac mass on chest radiograph. Computerised tomographic (CT) scan of the thorax was suggestive of pericardial cyst. Hydatid serology was negative. The cyst was excised.

Prevalence of tobacco use among school going youth in North Indian States.

BACKGROUND: Tobacco use, which is the cause of several respiratory diseases, generally starts in the teens. Global Youth Tobacco Survey (GYTS) is an international initiative to investigate the tobacco use in school going youth of 13 to 15 years of age. This report describes the GYTS findings in the North Indian region. METHODS: A two-stage cluster sample was used with selection of schools on probability proportional to enrollment size followed by systematic equal probability sampling with a random start of classes from each school. The 85-item questionnaire included 'core GYTS' and other additional questions. Data analysis was performed using EpiInfo 3.2 software and the results accounted for the complex sampling design and weighting factors in the data set. RESULTS: The sample consisted of 9319 students out of the total eligible population of 30488 from 100 schools. The prevalence of ever-use of tobacco varied between 2.9 to 8.5% in boys and 1.5 to 9.8% in girls. The prevalence was highest in Chandigarh and lowest in Punjab. Between 16 to 46% of students were exposed to the habit of tobacco among parents or friends. There were 10 to 34% students who were passively exposed to environmental tobacco smoke. CONCLUSION: Tobacco use is present in up to 10 percent of school going youth in the region. A majority of them had desired to quit. Tobacco control and cessation programmes therefore, remain important health issues.

Clinical and bacteriological profile of community acquired pneumonia in Shimla, Himachal Pradesh.

BACKGROUND: Community acquired pneumonia (CAP) is a common clinical problem. The present study was designed to evaluate the clinical and bacteriological profile of CAP in Shimla. METHODS: Seventy patients with community acquired pneumonia were enrolled in this study. In all the patients blood culture, sputum culture, pleural fluid culture (if available) and serological studies for the detection of Mycoplasma pneumoniae specific IgM antibodies by enzyme linked immunosorbent assay (ELISA) were done. RESULTS: Of the 70 patients, 53 (75.6%) had an identifiable atiology with 12 patients having evidence of mixed infection. No organisms could be isolated in 17 patients inspite of using serological methods for Mycoplasma pneumoniae, invasive procedures like bronchoscopic aspirations in addition to the conventional methods like sputum culture, blood culture and pleural fluid culture. The most frequent pathogen was Streptococcus pneumoniae (n = 19; 35.8%) followed by Klebsiella pneumoniae (n = 12; 22%), Staphylococcus aureus in (n=9; 17%), Mycoplasma pneumoniae (n = 8; 15%), Escherichia Coli (n = 6; 11%), beta-haemolytic streptococci (n = 4; 7.5%) and other Gram-negative bacilli (n = 5, 9%). CONCLUSION: Age smoking and under lying co-morbid conditions specially chronic obstructive pulmonary disease (COPD) were significantly associated with the development of CAP (p < 0.01).

Effect of fiberoptic bronchoscopy on arterial blood gases and cardiac rhythm at a moderate altitude of 2250 meters.

OBJECTIVES: To study the effects of fiberoptic bronchoscopy (FOB) at an altitude of 2250 m on arterial blood gases (ABG) and cardiac rhythm abnormality. METHODS: Fifty consecutive patients undergoing fiberoptic bronchoscopy were evaluated for the arterial blood gases and cardiac rhythm changes at Shimla (a moderate altitude of 2250 m), where there is a state of ambient hypoxia. RESULTS: The changes were noted in five stages ranging from the levels before the procedure till 15 minutes after the completion of the procedure. The mean fall in PaO2 levels in this study was 8 +/- 2.45 mm Hg and the fall was maximum at the end of procedure. Both smokers and nonsmokers showed a significant fall but the fall was more severe in smokers. The mean fall in SaO2 in this study was 3%. The increase in heart rate and blood pressure during FOB was significant as compared to baseline levels. There was no significant change in PH, PaCO2, HCO3. The commonest rhythm abnormality noted was sinus tachycardia which was well tolerated. No major cardiac arrhythmia was noted. It was further seen that the duration of the procedure and type of special procedure undertaken did not effect the levels significantly. Cyanosis was the commonest complication encountered (36%) and was seen more frequently in smokers and those with age more than 40 years. It was observed during the induction of bronchoscope and also during the further negotiation of the bronchoscope into the smaller branches of bronchial tree. CONCLUSION: The changes in ABG and cardiac rhythm are comparable to the studies at sea level except the increased incidence of cyanosis.

Effectiveness of salmeterol in stable COPD.

Thirty patients of stable chronic obstructive pulmonary disease (COPD) were studied for evaluation of effectiveness of inhaled salmeterol in a double blind, randomised, placebo controlled trial for seven days. Baseline spirometery and breathlessness score after 6 minutes walk test were assessed in all patients. Bronchial asthma was excluded in each patient by reversibility test with 200 ug of salbutamol inhalation. After inhalation of two puffs from a given inhaler through spacer device in the morning, spirometery was carried out 1, 3, 6 and 12 hrs after inhalation on day 1, 3 and 7 of trial. Six minutes walk test and breathlessness score were assessed after 3 hrs of inhalation on days 1, 3 and 7. The maximum bronchodilator response to salmeterol was observed on 7th day at three hours after inhalation. The mean increase in FEV1 was 29.2% of baseline value, which was significant as compared to placebo where the mean increase in FEV1 was 3.3% of the baseline value. The peak rise in FEV1 was observed at three hours after inhalation on all the three days. The bronchodilator effect of salmeterol persisted for upto 12 hours. The mean maximum increase in walking distance in 6 minutes walk test was observed on 7th day in salmeterol group, which was 50.7 metres whereas in placebo group it was 12.2 meters. The patients in salmeterol group perceived less breathlessness after the six minutes walk test. The study concluded that salmeterol 50 micrograms twice a day is effective in improving lung functions in patients with stable COPD and can be recommended as maintenance therapy for stable COPD patients.

Spectrum of cystic variants of Wilm's tumour: cystic nephroma (multilocular cyst) and cystic partially differentiated nephroma--a report of four cases.

Two cases of cystic nephroma (multilocular cyst of the kidney), and one case each of cystic partially differentiated nephroblastoma (CPDN) and rhabdomyomatous Wilms' tumour are described. All were male and in the pediatric age group. Grossly tumours were unilateral, unicentric and multiloculated. The need for proper designation of these lesions is highlighted because of difference in the treatment and prognosis of these tumours.